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Wednesday, June 11, 2008

Do I need a Laparoscopy?

As the son and brother of general surgeons I am often put in the position of defending the low volume of surgery that I perform as a reproductive endocrinologist. In years past, fertility physicians were often in the operating room spending hours repairing damaged fallopian tubes in an attempt to improve a patient’s fertility. However, as IVF technology has improved the need for laparoscopy has dwindled. I explain it to patients in this fashion: If I do a laparoscopy and find significant adhesions (scar tissue) and endomteriosis then IVF is your best option. And if I find minimal endometrosis and minimal scar tissue then IVF is your best option. And if I find that everything is normal then IVF is your best option.

So almost all roads lead to IVF so why do the laparoscopy? Well, not all patients can afford IVF or wish to try IVF. They may be afraid of the drugs, of OHSS, of multiples and I agree that those are good things to fear….and yet IVF really works better than our other options. Natural cycle IVF can remove some risk is more acceptable to some patients but it doesn’t work as well as stimulated cycle IVF. So do I need a laparoscopy? That is the topic of today’s question from 100 Questions and Answers about Infertility. So to honor my general surgeon father in light of the rapid approach of Father’s Day…here is my response…and it pretty much proves that I am not a “real” doctor in his eyes…

11. What is a laparoscopy, and do I need one?

A laparoscopy is an outpatient surgery usually performed under general anesthesia. Most laparoscopies are completed in a hospital, but some physicians utilize freestanding outpatient surgery centers. During a laparoscopy, the physician inserts a small fiber-optic telescope into the abdominal cavity through an incision made in the patient’s umbilical area (belly button). Most physicians initially distend the abdomen using carbon dioxide gas with a needle (Veres needle) to create what is called a pneumoperitoneum. A trocar—an instrument with a diameter similar to that of a pencil—is then passed through the umbilicus, allowing for introduction of the telescope (called a laparoscope) into the abdomen.

Using the laparoscope, a gynecologic surgeon can inspect the uterus, fallopian tubes, and ovaries. The appendix and upper abdomen are carefully inspected as well. Additional instruments may be inserted into the abdomen through incisions (ports) made along the hairline above the pubic bone. For example, the physician may use graspers, scissors, or suction irrigators to rinse the tissue and remove blood and fluids as needed. Some physicians insert a slightly larger telescope through the umbilical port, which allows them to use a carbon dioxide laser to cut scar tissue or destroy implants of endometriosis. Besides the laser, other instruments can be used to cut or burn abnormalities such as endometriosis or scar tissue.

During a laparoscopy, the physician typically introduces a blue dye into the uterine cavity while directly visualizing the fallopian tubes. If the fallopian tubes are patent (open) but are located in an abnormal location because of scar tissue, then the surgeon may try to free the fallopian tubes to improve the patient’s fertility. If abnormal ovarian cysts such as endometriomas are present, then the physician may remove them during the course of the laparoscopy or, if necessary, perform a laparotomy.

A laparotomy is a surgery performed through a larger incision, usually made along the bikini line. It may require the patient to stay 1 to 3 days in the hospital following the surgery. In addition, a laparotomy requires a longer recovery period and may create more new scar tissue than laparoscopic surgery. Certain abnormalities cannot be easily treated through laparoscopy, including exceedingly large ovarian cysts, ovarian cysts that are suspicious for cancer, and fibroids that are deeply embedded in the wall of the uterus. Patients with these problems are probably better served by a laparotomy.

For many years, all women who were seeking fertility care underwent laparoscopy as part of the initial evaluation. In recent times, this practice has faded with increased utilization of IVF. Although IVF has essentially replaced tubal surgery in patients with tubal factor infertility, laparoscopy is still used to correct certain problems in patients prior to undergoing IVF. Complications of laparoscopy are rare but can include injury to the bowel, bladder, and blood vessels; a need for laparotomy; and even death.


Jeremy said...

I recently had a laparoscopy and wa disgnosed with stage IV endometriosis. I am 25 and otherwise very healthy. My RE has recommended that we procede with IVF. Do you agree that this is our best (and possibly only) option?

DrG said...

No doubt that IVF is best choice in such cases. Have seen spontaneous pregnancies and could consided clomid/IUI in select patients who are Stage IV only because of an endometrioma but have normal tubes and no endo anywhere else....

Good luck.

Anonymous said...

I had my first IVF cycle recently..Couldnt go beyond egg retrieval coz my progesterone level was very high 3.53 even before eggg retrieval.I have one sided hydrosalphinx.Planning to undergo FET next month.Do you think I need laparoscopy and fix it before I proceed with FET to improve my chance of pregnancy??

Anonymous said...


DrG said...

We believe that a hydrosalpinx should be removed before any ET. I would discuss with your RE.

The specific concerns about laparoscopy should be discussed with your MD. Risks of this surgery are small but you need to discuss these with the surgeon not with me. Most patients are back to normal activities within a few days to a week.

Good luck


Anonymous said...

I was 20 when dx with Crohn's and had 8 surgeries to repair bowel perforations as well as infections. I am now 30 and show low progesterone levels but HSG test show no blockage. The RE said not to do the lap surgery since nothing can be fixed if I have a lot of scar tissue. He thinks the tubes and detached. My research is conflicted and I can't figure out if the surgery can actually fix anything. Is it worth it or should I only go straight to IVF? I haven't had any other fertility treatments in the 2 plus years of trying. Thanks- L

Anonymous said...

I recently had a laparoscopy and was found to be all clear, but I did bleed for a few days later. What I would like to ask is have this procedure does it effect your monthly cycle in any way as I was due a 3 days ago and I havent started as yet I did do a pregnacy test the day I was due but it was negative, so your advise would be appreciated.

Anonymous said...

From my HSG test my RE said and showed me that my Left tube appears to be blocked. He is recommending me have a laparoscopy so he can really know what the problem is. I would like to know if this is really necessary?

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Anonymous said...

Dear Dr G, my situation is kind of complicated. I had a myomectomy & a wedge rescetion (spelling) surgery in Dec 2011. My gyn told me to ttc after 8 months and after performing an HSG which I did last year in OCtober. But even before that we've been ttc but no success until now. In January 2012 I went to see my gyn and I was told I have 6cm cyst on my right ovary. Not to foget, my periods have been regular since even before the surgery. However we have been trying since but no luck. What could be the problem. We have spent a lot already we are just disappointed each month. Plz advise.

DrG said...

Hi Anonymous (4/16/13)

Well seems like you should discuss options with a fertility MD. Maybe IVF would be best choice. Hopefully the cyst will resolve but if not then a laparoscopy may be reasonable....

Good luck